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�� Tw SAN JOAQUIN-LOCAL HEALTH DISTRICT <br /> _FOR OFFICE USE: 1601 E. Hazelton Ave.; Stockton, Calif, <br /> Telephone; (209) _466-6781 <br /> F <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED / <br /> Date Issue'dY <br /> Application is hereb <br /> (Complete In Triplicate) '"` <br /> y made to` the San Joaquin Local Health District for a permit to construct <br /> t and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and "Regulations' of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �6 <br /> CENSUS TRACT <br /> Owner's Name - <br /> y Phone <br /> Address <br />' City <br /> Contractor's Name G <br /> r F License # <br /> �G?:T�1 Phone <br /> r <br /> TYPE OF WORK (Check); NEW WELL /7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other ',-/ <br /> DISTANCE TO NEAREST: SEPTIC -TANK SEWER LINES PIT PRIVY <br /> `y . <br /> SEWAGE .DISPQSAL FIEII3 CESSPOOL/SEEPAGE PITOTHER <br /> ti <br /> INTENDED USE ,, TYPE.-OF WELL -_ <br /> Industrial ' '-•- CONSTRUCTION SPECIFICATIONS <br /> ----- Cable Tool Dia. of Well Excavation <br /> Domestic/private " ' Drilled Dia. of We11 Casfng <br /> Domestic/public f Driven Gauge of Casing <br /> Irrigation = Grayel Patk• Depth of GrbutSealt <br /> Other Rotary. ''• "' Type _of .Grout Other Information <br /> (� <br /> ormation ' <br /> PUMP INSTALLATION Contractor ` <br /> Type of ;Pump H.P. <br /> ,r <br /> PUMP REPLACEMENT: /_7 State Work.Done <br /> PUMP REPAIR: <br /> _ / / State Work Done,....,, <br />.)ESTRUCTION OF WELL: Well Diameteroo, `s <br /> Approximate Depth �— <br /> Desc be Material and Procedure <br /> I hereby agree to compl with 'all laws and egulations of the San Joaquin Local Health District <br /> and the State -of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my .knowle'dge and belief. <br /> i <br /> SIGNED i �".. ""a..' <br /> TITLE <br /> t (DRAW PLOT,PLAN ON REVERSE SIDE <br /> PHASE I I 'FOR DEPARTMENT USE ONLY. . . <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS:. DATE 41 _ 0 - <br /> PHASE II GROUT INSPECTION _ - <br /> PHASE III FINAL INSPECTION <br /> INSPECTION Bt INSPECTION BY - DATE <br /> CALL FOR A GROUT INSPECTION. PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M C45 <br />